Search Results for: Stroke in ICD-11

Stroke Definition in the ICD-11 at the WHO

strokedef_table1By Bo Norrving, MD, Didier Leys,  Michael Brainin and Steve Davis

Health classifications are a core responsibility of the World Health Organization (WHO), assigned by international treaty with 193 member countries. The International Classification of Diseases (ICD) is the oldest and historically most important. Member countries are required to report health statistics to WHO according to ICD, and ICD categories also are used as the basis for eligibility and payment for health care, social and disability benefits and services. ICD should have broad global utility, not only for specialists or neurologists, but for all physicians and health workers. All global regions are represented on WHO advisory groups, with a good representation of low- and middle-income countries.

ICD-10 was completed in 1990; the interval to ICD-11 is the longest time without revision in history of the ICD. The period has seen major advances in our understanding of cerebrovascular diseases and their treatment. The ICD-11 is mandated by the World Health Assembly and is expected to be officially approved by the 2015 World Health Assembly. A novel feature of ICD-11 is the inclusion of definitions. At WHO, the Mental Health and Substance Abuse Department is responsible for the revision of Diseases of the Nervous System. The Neurology Topic Advisory Group is chaired by Raad Shakir, and has seven individual members and more than 10 representatives from neurology associations and federations.

The World Stroke Organization (WSO) has been involved in the ICD-11 revision at WHO since 2010 and has been invited in this function as the NGO in official relations with WHO regarding stroke. The Cerebrovascular Disease ICD-11 advisory group is chaired by Bo Norrving, Sweden, with members Valery Feigin, New Zealand; Padma Gunarathne, Sri Lanka; Vladimir Hachinski, Canada; Michael Hennerici, Germany; Ming Liu, China; Peter Rothwell, UK; and Jeffrey Saver, US.

In the ICD-11, all cerebrovascular diagnoses will for the first time form one single block within Diseases of the Nervous System, which represents a major change in the classification. The work of the ICD-11 cerebrovascular working group has been reviewed by the board of the WSO and has been openly available to public comments. The document has been submitted to WHO, and the next steps include international scientific peer review of the whole ICD-11 and field trials. The aim is that the ICD-11 in its complete form is submitted to the 2015 World Health Assembly, for subsequent implementation in member countries.

Selected key categories of the ICD-11 and their definitions are summarized in Table 1. The term “stroke” requires the presence of acute neurological dysfunction, which is in line with the definitions generally used in previous epidemiological studies, official statistics and the Global Burden of Disease project. This requirement was felt to be of particular importance in low- and middle-income countries in which a large proportion of cases will be diagnosed based only on clinical features without the addition of neuroimaging. Keeping the requirement of acute neurological dysfunction for stroke will allow comparison of data between regions and between time periods for the study of trends, which are extremely important for monitoring of global burden of diseases.

The ICD-11 cerebrovascular section includes a new cause category: “Cerebrovascular disease with no acute cerebral symptoms” which includes silent cerebral infarcts, silent cerebral microbleeds and silent white matter abnormalities associated with vascular disease.

“Silent cerebral infarct” is defined as an infarct demonstrated on neuroimaging or at autopsy that has not caused acute dysfunction of the brain. There is substantial scientific support that silent cerebral infarcts carry important consequences on brain function (cognition, gait, balance function) and prognosis. Whereas effects of specific therapies have not been demonstrated yet, risk factor assessment and control should usually be applied for preventive purposes. However, the risk of disease stigmatization also was carefully considered, and it is specifically stated that these entities do not represent a “stroke,” a distinction that may have unwanted consequences from legal or insurance perspectives.

More than 90 percent of all cerebrovascular lesions in the brain are not associated with acute neurological dysfunction; in the general elderly population the prevalence of silent cerebral infarcts and microbleeds range from one-fifth to one-half with increasing age. Use of different stroke definitions that do, or do not, include silent cerebral infarcts and microbleeds, carry a potential risk of miscoding that may seriously distort official statistics and of causing confusion within the health sector and to the general public.

As the current WSO president, Norrving was invited to the AHA/ASA working group, but when it became apparent that the group would arrive at a definition of stroke that was importantly different from the one in ICD-11 (basically the inclusion of silent cerebral infarction and silent cerebral hemorrhage within the lexicon of stroke), the issue was discussed within the organization and the decision was taken that WSO needed to withdraw.

WSO cannot officially approve another definition of stroke than the one developed within the governmental framework of the ICD-11 at WHO. Similarly, Didier Leys, as the current ESO president, was also invited to the AHA/ASA working group; ESO took the decision also to withdraw as the organization supported the definition of stroke as defined in the ICD-11, and also argued that definitions on cerebrovascular disease should be taken on a world, rather than a regional, level.

For the future, it is essential that transparent definitions are used that facilitate reporting and comparisons on a global scale. Stroke is one of the prioritized non-communicable diseases within the WHO Global Action Plan for NCDs 2013 to 2020, and the prevention and management of stroke requires the full support of all actors involved, including the stroke and neurological societies.

Norrving is immediate past president WSO and chair of the ICD-11 Cerebrovascular Advisory Group. Leys is immediate past president ESO. Brainin is ESO president. Davis is WSO president.

World Stroke Day Congress in Moscow

Three days of powerful presentations on stroke

By Peter Sandercock, MD, DM, FRCPE, FMedSci, FESO

Peter Sandercock, MD, DM, FRCPE, FMedSci, FESO

More than 2,800 neurologists and other physicians involved in stroke care attended World Stroke Day Congress Oct. 25-27 in Moscow. Attendees were from Moscow and more than 60 regions of Russia and 10 other countries, mostly Eastern European. There also were representatives of stroke support groups.

The meeting was held in the iconic Ukraina Radisson Royal Hotel Conference Center in central Moscow. The conference was organized by Prof. Eugene Gusev, president of the All-Russian Society of Neurologists, and  Prof. Alla Guekht, secretary of the All-Russian Society of Neurologists and the World Stroke Organization, with the support of the Ministry of Health of the Russian Federation, the Russian Academy of Sciences, Moscow Healthcare Department, Pirogov Russian National Research Medical University, All-Russian Society of Neurologists, and the Moscow Research and Clinical Center For Neuropsychiatry.

In the spirit of international collaboration and scientific exchange of ideas and solutions to tackle the global burden of stroke, the conference was supported by representatives from major international stroke and neurological organizations: the World Federation of Neurology (WFN), European Academy of Neurology (EAN), American Academy of Neurology (AAN), European Stroke Organization (ESO), and the International League Against Epilepsy (ILAE).

The congress focused on the latest developments in stroke prevention, acute management, and restorative care after stroke, as well as on raising awareness about stroke and the need for better resources, sharing experiences in dealing with problems resulting from stroke, and providing relevant information to stroke survivors and their caregivers.

The congress book contained extended abstracts of all of the talks and was published in English and Russian. The participants of the congress received the book for free. As many doctors in the former Soviet Union know English poorly, these books are extremely valuable for them.

Education Sessions and Symposia

Demonstration of innovative stroke rehab technology at Moscow Research and Clinical Center of Neuropsychiatry.

Day 1: The congress got off to a great start, with the program for the day including sessions on stroke in the young, rehabilitation after stroke, chronic cerebrovascular disease, clinical pharmacology and pharmacotherapy of stroke, current technologies in endovascular treatment of acute ischemic stroke, management of stroke — challenges and solutions, organization of stroke care, and a master class on multiple organ failure in severe stroke. 

The WSO members on the faculty who gave talks on Day 1 were Geoff Donnan on “Thrombolysis, Modern State and Perspectives,” Peter Sandercock on “Personalized Medicine: Can it Be Applied in Stroke and Can it Be Tested in Trials?” and Wolfgang Grisold (from WFN) on “Stroke and Cancer.”

Main Scientific Sessions

Day 2: The scientific congress was formally opened by a Praesidium of Representatives of all the key organizations in contributing to the congress, with welcoming words from Parliament of the Russian Federation, Russian Academy of Sciences, local organizers A. Guekht and E. Gusev, and W. Hacke (representing WSO).  The ESO was represented by V. Caso, EAN by D. Leys, WFN by W. Grisold, and ILAE by E. Perucca.

It was followed by a series of expert talks from Russian colleagues, covering a wide variety of issues on current stroke care in the region. The afternoon sessions included updates on current standards in stroke diagnosis, the role of neuropsychiatry in stroke, novel opportunities in stroke recovery, thrombolysis, and a masterclass in chromotherapy. There was an important session on cerebrovascular disease in ICD-11 with talks by S. Murasev and E. Salakhov (representatives of the Ministry of Health) on the “Role of the Russian Federation in International Program Against Brain Diseases,” B. Norrving (WSO) on “Stroke as a Brain Disease in ICD-11 – What Does it Mean?”, R. Sacco (AAN) on “Stroke Prevention and Brain Health Support” and V. Caso (ESO) on “Gender Differences in People with Ischemic Stroke.” There also was a key session on post-stroke epilepsy with talks by A. Hauser and S. Moshe from the U.S., Prof. Guekht and  E. Perucca (Italy).

Scientific Sessions

Prof. Guekht, Prof. N. Bornstein, and Immediate Past President of WSO Prof. S. Davies discuss stroke rehabilitation.

Day 3: The main plenary session was opened by Prof. Veronika Skvortsova, the Minister of Health, and was followed by the Award of Diploma of the Foreign Members of the Russian Academy of Sciences. This was followed by a series of talks on major stroke topics: “Intravenous Thrombolysis — Is it Still the Most Important and Specific Method of Acute Stroke Therapy?” W. Hacke; “Cognitive Impairment After Stroke Is a Heavy Burden for Patients, Their Families, and Society,” M. Brainin; “Reperfusion Therapy and Ischemic Penumbra,” S. Davis; “Arterial Hypertension and Stroke,” E. Chazov, I. Chasova; “Approaches to Lowering Cardiovascular Disease Mortality in Russia,” S. Boitsov; “Surgical Treatment of Stroke in Russia,” V. Krylov; and “Spinal Cord Circulation Disorders,” A. Skomorets.

This session outlined the great progress that has been made in reducing the burden of stroke and vascular disease over the past decade, but also highlighted the priority actions for the future. Other interesting contributions of the day included sessions on stroke in childhood, ultrasound in diagnosis, “Eye as a Mirror of the Brain,” by N. Bornstein and a session on post-stroke cognitive impairment.

Visit to Moscow Research and Clinical Center For Neuropsychiatry

Prof. Guekht arranged a fascinating and most enjoyable visit for the international faculty to her institution, at which research fellows presented their work on various aspects of cognition, neuroimaging, neuropsychiatry, and rehabilitation. She invited her colleagues and collaborators to attend this meeting and present their institutions, so there was a possibility to get acquainted with the best University Hospitals/Clinical Centers in Moscow: the Clinical Medical Center of the Moscow University of Medicine & Dentistry, Buyanov Moscow City Hospital of the Healthcare Department of Moscow, and others.

This was an excellent opportunity for scientific exchange and discussion. The significant achievements in the Moscow medical system — modern equipment, new technologies, and well-trained doctors — were very impressive; the Buyanov Moscow City Hospital and the Moscow Research and Clinical Center of Neuropsychiatry were the perfect examples. The grounds of the center include new buildings as well as some beautiful historic ones that have been renovated and preserved as monuments to the long scientific heritage of the unit.•

Sandercock is Emeritus Professor of Medical  Neurology at the University of Edinburgh, U.K.

Stroke: Back to Where It Belongs

By Raad Shakir, MD

Raad Shakir, MD

If someone anywhere in the world had a stroke or a TIA in the last 60 years, the World Health Organization (WHO) coding system placed the event under either vascular diseases or episodic symptoms, not in the appropriate central nervous system chapter of ICD-10. This situation started with ICD-7 in 1955 and has continued since. It skews all statistics of neurological diseases produced by the WHO. ICD-10 has been in use since 1990, and a total revamp is long overdue. The information is not only stale and old, but incorrect. Codes such as “slow virus infection” for prion diseases are expected to be used in the 21st century?

The WHO Department of Mental Health and Substance Abuse, where neurology sits, commissioned a Neurosciences Topic Advisory Group (Neurology TAG) in 2009. I have had the privilege of chairing the TAG, which expanded to involve specialists from all neuroscience specialties. The tasks were huge and detailed. The aim was to produce ICD-11, which will both serve the needs of the non-specialists as well as those working in highly developed institutions.

Brain imaging studies capture the evolution of acute ischemic stroke in two patients.

Perhaps the most important ICD-10 anomaly the TAG faced was the situation of cerebrovascular diseases (CVDs) and their future placement in ICD-11. Attempting change of the basic architecture of ICD-10 required a major case to be made on the reasoning and practicality of changing an existing status. CVDs fell under Circulation Disorders on the premise that they are a disease of vessels. Statisticians, following the principle of ascribing disorders to their basic etiology, followed this procedure, ignoring the fact that all of the effects of CVDs are neurological and that the initial interaction of the neurovascular bundle is fundamental to the pathophysiology. Moreover, in ICD-10, other ischemic disorders affecting the eyes, bowels, and kidneys fall under the affected organs. Transient ischemic attacks were classified under episodic disorders separate from CVDs.

This situation is not only incorrect, but it has led to massive confusion of reporting the fact that a leading cause of death is not placed as a disease of the brain. The first act the TAG performed was to contact and agree with our cardiology colleagues as cardiac events were lumped with CVDs, skewing their statistics as much as ours. They were asked to approve a total separation of cardiac and brain diseases for the benefit of both. This was successfully established with the Cardiology TAG in 2011. It, of course, remains that cardiogenic causes of CVDs are appropriately reported in both sections.

Where to Place CVDs?

The WHO statisticians were informed, and we had “initial acquiescence” until the middle of 2016, when a major statistician’s review of ICD-11 was carried out by the WHO Department of Informatics and Statistics. At that time, statistics advisers had second thoughts, which again placed all CVDs under the circulation section of the Joint Linearization for Mortality and Morbidity section of ICD-11. 

This decision needed to be reversed, which required intensive lobbying to make the point that stroke is a brain disease. It has to be emphasized that the ICD is “owned” by the WHO statisticians, and our role as clinicians is advisory.

Be that as it may, the TAG had to pursue this matter vigorously and provide the scientific reasoning for the change. WFN and the World Stroke Organization (WSO) acted in a closely coordinated manner. Professor Bo Norrving, past president of the WSO, and I, the representatives of the Neurology TAG, used all possible avenues to make the case for the WHO Department of Informatics and Statistics. In addition to the production of scientific evidence on the etiology of stroke and the interactions between vessels and brain parenchyma, we needed to mobilize other players to reinforce the message of the importance of stroke being classified as a brain disease for resource allocation and training of staff—medical, nursing, and others—to combat the scourge of CVDs.

The issue is vital for the future of neurology, and The Lancet published two letters, one from us1, and the second a reply from the WHO Department of Informatics and Statistics2. We had put forward the argument for stroke moving to the central nervous system, while the ICD classification team put forth its reasoning, quoting continuity and the fact that CVDs were placed in ICD-7 in 1955.

This meant going to governments, as they are the ultimate power in the WHO structure. We are most grateful for the support, such as a most powerful letter from Veronica Skvortsova, the minister of Health of the Russian Federation, addressed to the WHO director general. Dr. Skvortsova is herself a neurologist and therefore is fully aware of this anomaly in ICD-10. We also are most indebted to the health ministries of Austria and New Zealand for their support.

We were hugely supported by patient organizations that wrote to the WHO and to neurologists from across the world for their support. Following all of this effort, a request came from the ICD classification team asking us to have another face-to-face meeting. This was conducted Dec. 21, 2016, in Geneva. The daylong meeting was most interesting as it started with the assertion of the statisticians on the importance of continuity and stability of statistics over decades. This is something crucial to us all. However, explanations were provided with regard to the need for radical change and why it is crucial to rectify a previous anomaly. The WHO technical department where neurology sits was represented by Dr. Tarun Dua, who made the case for the need to place CVDs under the nervous system diseases chapter of the ICD-11. The Neurology TAG was represented by Dr. Norrving and me. The meeting ended without an immediate outcome. We did not know the meeting’s conclusions for more than three months. The WHO ICD team had to clear its decisions with its statistics consultants from around the world. This is perfectly understandable as many computer systems have to be retuned, and this will need time and finance.

Two further medical statistics meetings took place. Finally, on March 31, I was informed by email: “The grouping ‘Cerebrovascular Diseases’ has moved into ‘Diseases of the Nervous System.’” This is a culmination of eight years of work and is the most logical outcome for our endeavors.

Now the world of neurology is correctly represented. This is immediately reflected in the soon-to-be-published “Global Burden of Disease” paper, where in 2015 “neurological disorders rank as the leading cause group of DALYs (disability-adjusted life years) and the second-leading cause of death in the world.” This means that resources will be appropriately allocated not only for CVDs but all neurological disorders. The WHO decision was truly momentous, and for that we are grateful. Stroke is back where it belongs. 


  1. Shakir R, Davis S, Norrving B, Grisold W, Carroll WM, Feigin V, Hachinski V. Revising the ICD: stroke is a brain disease. Lancet 2016; 388:2475-6.
  2. Boerma T, Harrison J, Jakob R, Mathers C, Schmider A, Weber S. Revising the ICD: explaining the WHO approach. Lancet 2016; 388: 2476-7.

Implications of the AHA/ASA Updated Definition of Stroke for the 21st Century

ahaasastroke_table1By Scott E. Kasner, MD,  and Ralph L. Sacco, MD

Note: The views expressed by the authors  are their own and do not represent an official statement by the American Heart Association/American Stroke Association.

Stroke was defined by the World Health Organization (WHO) more than 40 years ago as “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.”1 This was a working definition created for a study assessing the prevalence and natural history of stroke, and it served its purpose at the time.

The ensuing decades have witnessed major advances in basic science, pathophysiology and neuroimaging that have dramatically improved our understanding of ischemia, infarction and hemorrhage in the central nervous system (CNS). There is little doubt that permanent injury occurs well before the 24-hour threshold, and therefore purely time-based definitions are inaccurate and obsolete. Further, neuroimaging has demonstrated that clinically transient symptoms are often associated with evidence of acute cerebral infarction and that infarction may occur without overt symptoms.

In 2009, the American Heart Association/American Stroke Association (AHA/ASA) published a scientific statement redefining transient ischemic attack (TIA) as, “a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia without acute infarction.”2 This statement formally addressed only one side of the proverbial coin, but clearly implied that objective evidence of infarction should be considered as a defining feature of stroke.

In the spring of 2013, the AHA/ASA published an expert consensus document with a new definition of stroke to reflect these advances.3 Authors with expertise in the fields of neurology, neurosurgery, neuroradiology, neuropathology, clinical research methods, epidemiology, biomarkers, policy and global public health were invited from within the AHA/ASA, as well as the American Academy of Neurology, the American Association of Neurological Surgeons and Congress of Neurological Surgeons, U.S. Centers for Disease Control and Prevention, the National Institute of Neurological Disorders and Stroke, the European Stroke Organization (ESO), the World Stroke Organization (WSO) and others to establish a universal definition of stroke.

The key components of the new AHA/ASA definition are summarized in Table 1. The major fundamental change compared with older definitions is that the new broader definition of stroke includes any objective evidence of permanent brain, spinal cord or retinal cell death due to a vascular cause based upon pathological or imaging evidence with or without the presence of clinical symptoms. The new definition harmonizes with our understanding of the pathophysiology of infarction and with the recent redefinition of TIA, but also necessitates the inclusion of silent infarction and silent hemorrhage within the broad definition of stroke. Ultimately, the leaders of the ESO and WSO withdrew from participation and declined to endorse the statement because they disagreed about the inclusion of silent cerebral infarction and silent cerebral hemorrhage within the lexicon of stroke. (See “Stroke Definition in the ICD-11 at the WHO.“)

Objective Evidence of CNS Infarction: Imaging or Persistent Symptoms

The AHA/ASA defined CNS infarction based on pathological, imaging or other objective evidence of infarction. In the absence of this evidence, the persistence of symptoms of at least 24 hours or until death remained a method to define stroke. Objective evidence of infarction is generally currently available in the form of neuroimaging or less commonly neuropathological examination, but other methods such as highly sensitive and specific biomarkers may emerge in the future.

At present, imaging is not always available and also is not perfect. CT is well known to have limited sensitivity to acute infarction, especially in the first few hours, and also misses small infarctions even at later time points. MRI is far more sensitive, potentially within minutes of onset, but still fails for small infarctions, especially in the brainstem. In much of the developing world and in rural parts of more developed regions, neither of these tools may be available in the acute setting, if at all, which limits the global applicability of an imaging-based definition of stroke.

Persistence of clinical symptoms also can be taken as objective evidence of cerebral infarction. Several studies suggest that the majority of transient stroke symptoms resolve in less than 24 hours,4,5 and that persistence beyond 24 hours is almost always associated with MRI evidence of infarction. These findings support the classic threshold as a means to infer infarction when there is no confirmatory method readily available.

Definitions and Implications of Silent CNS Infarctions and Hemorrhages

CNS infarction included ischemic stroke, as well as silent CNS infarction (carefully worded to deliberately not use the term “silent stroke”). Ischemic stroke was defined as an episode of neurological dysfunction (clinical symptoms) caused by focal cerebral, spinal, or retinal infarction, while silent CNS infarction was defined as imaging or neuropathologic evidence of CNS infarction, without a history of acute neurological dysfunction attributable to the lesion. Similar definitions were crafted for cerebral hemorrhage. This major departure from past definitions is based on the observation of brain injury, either by imaging or pathological assessment, in patients without a history of well-defined neurologic symptoms.

Silent lesions have been recognized pathologically as infarctions and hemorrhages since the 1960s but were deemed of uncertain importance. However, they may not be entirely asymptomatic, as patients may have subtle cognitive, gait or other functional impairments in the absence of a typical acute presentation. To some extent, the “silence” of an infarction or hemorrhage depends on the eye of the beholder. Patients may not be aware of their symptoms due to neglect, denial or simply may attribute them to another cause and not seek a medical opinion. Physicians and other health care providers may vary in their ability to detect mild neurologic abnormalities, or they, too, may ascribe them to an alternative cause.

Silent CNS infarcts are well-recognized to be associated with impaired mobility, physical decline, depression, cognitive dysfunction, dementia and clinical stroke. Silent brain infarcts increase the risk of ischemic stroke by 2-4 times6,7 independent of other vascular and stroke risk factors. A recent review of MRI diagnostic criteria for silent brain infarcts found a threshold size of ≥3 mm to be a reliable indicator of these lesions. Silent infarcts are approximately 5 times more prevalent than ischemic strokes, found in 8 to 28 percent of patients, and are increasingly prevalent with age and in women.8-13 Chronic small parenchymal hemorrhages, or “microbleeds,” are found in up to 6 percent of healthy elderly individuals.14 These lesions, typically observed on gradient echo sequences on MRI, are the detritus of prior hemorrhages in the form of hemosiderin, typically adjacent to small blood vessels. Microbleeds appear to share the same underlying pathophysiology as larger hemorrhages, and are most commonly associated with cerebral amyloid angiopathy (CAA) and/or chronic hypertension. Since hemorrhage in the brain is always abnormal, there is no size threshold for microbleeds, unlike small infarctions. These microbleeds may not be associated with a clinical event but are associated with cognitive decline”‘5,16 as well as a high rate of subsequent ICH and ischemic stroke.17 As with silent CNS infarctions, the clinical impact may depend on the sensitivity of the observer.

The AHA/ASA included silent CNS infarctions and hemorrhages within the broadest definition of stroke for multiple reasons. First and foremost, since silent lesions have the same pathophysiology as clinically apparent ischemic and hemorrhagic strokes, it seems consistent that they should be united within the same broad disease category. Similarly, the multi-organization Universal Definition of Myocardial Infarction (MI),18 considered any pathologically defined cardiac infarction as an MI, regardless of the presence or absence of any symptoms or signs. Further, inclusion of silent CNS infarction and hemorrhage raises awareness of the potential for cognitive and functional decline that must be assessed and addressed from the perspectives of treatment and prevention. It seems clear that CNS infarctions and hemorrhages occur over a spectrum ranging from severe symptoms to very mild or even clinical silence, and the opinion of the AHA/ASA was that all must be included within the new and broader definition of stroke.

Implications for World Neurology

The new tissue-based definition of CNS infarction depends on either early objective (currently neuroimaging) evidence of infarction or persistence of symptoms for at least 24 hours. If early imaging is not available, then clinicians are left with a diagnostic dilemma in those first 24 hours since the event cannot be clearly classified as stroke. For patients with acute myocardial ischemia, the term “acute coronary syndrome” (ACS) is used before it can be determined if there is infarction or not, as assessed by electrocardiography or biomarkers. Similarly with stroke, the term “acute cerebrovascular syndrome” (ACVS) would suggest the potential diagnoses of cerebral infarction, TIA, and hemorrhage in patients presenting within the first 24 hours from onset and prior to the completion of imaging studies. Ultimately, diagnostic techniques and/or time will help define infarct or hemorrhage based on objective imaging, or TIA in the absence of positive imaging and resolution of symptoms within 24 hours from onset. A major challenge for the future will be the achievement of access to diagnostic and treatment tools in the developing world, where a substantial portion of the global burden of stroke occurs.

The inclusion of silent infarcts and microhemorrhages within the AHA/ASA definition of stroke opens many questions for clinicians. In regions with little or no access to neuroimaging, this change in definition may prove irrelevant for many years to come. However, for those with such access, silent lesions are likely to be detected as a result of the widespread use of MRI for non-cerebrovascular symptoms such as headache or dizziness. Further, clinicians and patients should be aware of the relationship between silent infarcts and hemorrhages with dementia and other impairments. The clinician should consider such patients as having evidence of cerebrovascular disease and should evaluate and treat any potential stroke risk factors. However, guidelines for secondary stroke prevention19 have been generated from clinical trials that have only included patients with symptomatic cerebrovascular disease and have not included silent infarcts. No studies have yet addressed the safety and efficacy of secondary prevention measures in patients who only have silent infarction. Future guidelines must address the available evidence for treatment in this population.

Updating the definition of disease can have prominent effects on disease surveillance and assessments of public health.  In the case of adding a large number of silent infarction cases to the existing number of stroke cases, this will increase the total number of stroke cases while likely decreasing the mortality rate due to the addition of a number of minor/silent cases.20 Updating the definition of stroke could result in reclassification of stroke cases for incidence, prevalence, and mortality in national and international statistics, disease classification coding systems and existing health surveys. This is particularly problematic if definitions are applied differently in each region of the globe, and this is a major concern of all stroke organizations. Therefore, the AHA/ASA recommended that symptomatic and silent infarctions and hemorrhages should be counted separately to allow for valid analyses of temporal and geographic trends in stroke. Although the WSO, ESO and WHO will not include the silent lesions within the definition of stroke, they recognize their importance and are going to start counting them within the scope of cerebrovascular disorders in the ICD-11.

Kasner is with the University of Pennsylvania and Sacco is with the University of Miami.


1.         Aho K, Harmsen P, Hatano S, Marquardsen J, Smirnov VE, Strasser T. Cerebrovascular disease in the community: results of a WHO collaborative study. Bull World Health Organ. 1980;58:113-130.

2.         Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E, Hatsukami TS, Higashida RT, Johnston SC, Kidwell CS, Lutsep HL, Miller E, Sacco RL. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke. 2009;40:2276-2293.

3.         Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, Elkind MS, George MG, Hamdan AD, Higashida RT, Hoh BL, Janis LS, Kase CS, Kleindorfer DO, Lee JM, Moseley ME, Peterson ED, Turan TN, Valderrama AL, Vinters HV. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:2064-2089.

4.         Levy DE. How transient are transient ischemic attacks? Neurology. 1988;38:674-677.

5.         Shah SH, Saver JL, Kidwell CS, Albers GW, Rothwell PM, Ay H, Koroshetz WJ, Inatomi Y, Uchino M, Demchuk AM, Coutts SB, Purroy F, Alvarez-Sabin JS, Sander D, Sander K, Restrepo L, Wityk RJ, Marx JJ, Easton JD. A multicenter pooled, patient-level data analysis of diffusion-weighted MRI in TIA patients. Stroke. 2007;38:463.

6.         Bernick C, Kuller L, Dulberg C, Longstreth WT, Jr., Manolio T, Beauchamp N, Price T. Silent MRI infarcts and the risk of future stroke: the cardiovascular health study. Neurology. 2001;57:1222-1229.

7.         Vermeer SE, Hollander M, van Dijk EJ, Hofman A, Koudstaal PJ, Breteler MM. Silent brain infarcts and white matter lesions increase stroke risk in the general population: the Rotterdam Scan Study. Stroke. 2003;34:1126-1129.

8.         Howard G, Wagenknecht LE, Cai J, Cooper L, Kraut MA, Toole JF. Cigarette smoking and other risk factors for silent cerebral infarction in the general population. Stroke. 1998;29:913-917.

9.         Kohara K, Fujisawa M, Ando F, Tabara Y, Niino N, Miki T, Shimokata H. MTHFR gene polymorphism as a risk factor for silent brain infarcts and white matter lesions in the Japanese general population: The NILS-LSA Study. Stroke. 2003;34:1130-1135.

10.       Longstreth WT, Jr., Bernick C, Manolio TA, Bryan N, Jungreis CA, Price TR. Lacunar infarcts defined by magnetic resonance imaging of 3660 elderly people: the Cardiovascular Health Study. Arch Neurol. 1998;55:1217-1225.

11.       Price TR, Manolio TA, Kronmal RA, Kittner SJ, Yue NC, Robbins J, Anton-Culver H, O’Leary DH. Silent brain infarction on magnetic resonance imaging and neurological abnormalities in community-dwelling older adults. The Cardiovascular Health Study. CHS Collaborative Research Group. Stroke. 1997;28:1158-1164.

12.       Vermeer SE, Koudstaal PJ, Oudkerk M,  Hofman A, Breteler MM. Prevalence and  risk factors of silent brain infarcts in the population-based Rotterdam Scan Study. Stroke. 2002;33:21-25.

13.       Vermeer SE, Longstreth WT, Jr., Koudstaal PJ. Silent brain infarcts: a systematic review. Lancet Neurol. 2007;6:611-619.

14.       Roob G, Schmidt R, Kapeller P, Lechner A, Hartung HP, Fazekas F. MRI evidence of past cerebral microbleeds in a healthy elderly population. Neurology. 1999;52:991-994.

15.       Qiu C, Cotch MF, Sigurdsson S, Jonsson PV, Jonsdottir MK, Sveinbjrnsdottir S, Eiriksdottir G, Klein R, Harris TB, van Buchem MA, Gudnason V, Launer LJ. Cerebral microbleeds, retinopathy, and dementia: the AGES-Reykjavik Study. Neurology. 2010;75:2221-2228.

16.       Werring DJ, Frazer DW, Coward LJ, Losseff NA, Watt H, Cipolotti L, Brown MM, Jager HR. Cognitive dysfunction in patients with cerebral microbleeds on T2*-weighted gradient-echo MRI. Brain. 2004;127:2265-2275.

17.       Fan YH, Zhang L, Lam WW, Mok VC, Wong KS. Cerebral microbleeds as a risk factor for subsequent intracerebral hemorrhages among patients with acute ischemic stroke. Stroke. 2003;34:2459-2462.

18.       Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD. Third Universal Definition of Myocardial Infarction. Circulation. 2012.

19.       Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, Halperin JL, Johnston SC, Katzan I, Kernan WN, Mitchell PH, Ovbiagele B, Palesch YY, Sacco RL, Schwamm LH, Wassertheil-Smoller S, Turan TN, Wentworth D. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke. 2011;42:227-276.

20.       Pia Sormani M. The Will Rogers phenomenon: the effect of different diagnostic criteria. J Neurol Sci. 2009;287 Suppl 1:S46-49.

Updating the Definition of Stroke: Seeing the Forest and the Trees

Donald H. Silberberg

Donald H. Silberberg


The American Heart Association and American Stroke Association (AHA/ASA) created a new definition of stroke that encompasses both clinically manifest and silent ischemic and hemorrhagic lesions of the brain. They based this decision on the common pathogenesis of these lesions, regardless of whether or not the injury was detected by patient or practitioner.

In other words, the AHA/ASA’s answer to the age-old question was, “If a tree falls in the forest and there is no one around to hear it, it does in fact make a sound.” In contrast, the World Stroke Organization, the European Stroke Organization and the World Federation of Neurology endorsed the International Classification of Diseases-11 (ICD-11), which requires the presence of acute neurological dysfunction to diagnose a stroke. They maintained the historical definition, which has been consistently used for decades of comparative studies and global monitoring.

These groups were concerned that the inclusion of silent lesions would create political and procedural problems with coding, statistics and public understanding. Their answer was, “The tree does not make a sound.”

However, the ICD-11 recognized the importance of silent lesions and will for the first time include a new category of cerebrovascular disease with no acute cerebral symptoms. All groups agree that silent infarcts and hemorrhages are important, but disagree about whether they should be called strokes. Nevertheless, all would probably make the same observation: “There are too many trees lying here on the forest floor. We need to clean them up and try to prevent more from falling.”

One can anticipate that discussions concerning these slightly differing approaches will continue, to the benefit of our patients and all concerned with stroke prevention, treatment and rehabilitation.

World Congress of Neurology, Vienna, September 2013

Enthusiastic congratulations are due to all who were responsible for organizing and executing the highly successful World Congress in Vienna. The Program Committee, led by Donna Bergen, assembled an outstanding series of lectures and courses. The members of the Austrian Society of Neurology were most gracious hosts. Support from the World Federation of Neurology helped to assure a significant presence of colleagues from economically pressed countries, a trend that we hope and expect will continue and increase. Reports concerning some of the activities that took place are in this issue. Importantly, the task now is to organize an equally, or even more successful 2015 World Congress of Neurology in Santiago, Chile.

World Congress of Neurology 2019 

As this issue of World Neurology is published, the excitement and tension surrounding the upcoming XXIV World Congress of Neurology (WCN) is building. All of those involved are readying their final preparations for what should be one of the most exciting, educationally informative, and varied gathering of speakers, attendees, and delegates from all over the world.

William Carroll, MD

Being a true World Congress of Neurology, it will have all the local flavor, international participation, and opportunity for collegial interaction that uniquely characterizes such meetings, setting it apart from the more regular annual regional meetings.

The Dubai WCN promises much. As a major travel hub, Dubai will reduce overall delegate travel time and offer a wide range of accessible quality accommodation and novel attractions. Most importantly, it has a first-class scientific and teaching program, guaranteed to be of interest to all.

The World Federation of Neurology (WFN) is most grateful to all those who have accepted the invitation to speak and to teach during this meeting. By accepting both roles, most of the invited speakers have aided the organizers and the WFN in substantially reducing the faculty costs, thus allowing more generous support in keeping with the recognition they deserve for their contribution. Furthermore, through reduced faculty costs and in partnership with the local Emirates Neurological Society, this WCN has been able to offer a record number of travel bursaries to assist the attendance of more than 200 young neurologists from low- and low-middle-income countries.

A further consequence of the modestly reduced faculty and the attempts of the program committees to engage more younger speakers (while also attaining topic, regional, and gender balance) is that some regular participants from past congresses may feel overlooked. To those who may feel this way, I would like to say that we have greatly appreciated their WCN contributions and in turn those to the WFN.

Other extraordinary highlights will include increasing the attractiveness of the Tournament of the Minds as described in my last column, the continuation of posters on poster boards rather than by e-format, the use of news conferences to disseminate important messages from the WCN, and upgraded social media. The decision to retain physical poster sessions is based on the observations at a number of other conferences of the relative sterility of e-poster sessions and the organic interactive environment seen at physical poster sessions. Delegate feedback here remains important.

There are three important press conferences planned. It is no coincidence that these will focus on the three largest contributors to the global disability adjusted life years. The first is the final activity for the successful 2019 World Brain Day – Migraine the Painful Truth. This press event will be co-hosted by the International Headache Society (IHS) and the WFN and will emphasize the impact that migraine has not only on the individual and on them as employees but also on their employers.

The second press conference will focus on the nexus between stroke and dementia, and the third on the recent alignment of the World Health Organization (WHO), WFN and the World Stroke Organization (WSO) through the change in categorization of stroke in ICD-11 from a circulatory disease to a brain disease and the implications of this.

Council of Delegates

The WCN also provides an important opportunity for groups to meet and discuss a wide range of issues related to neurology and neurology specialties. For the WFN, this is one of the most important times. The WFN Council of Delegates (COD), comprising representatives from most of the WFN national member organizations, meets Oct. 26 to conduct its business.

On this occasion, there are two trustee positions to be filled. These are the treasurer and an elected trustee. An important vote will also be held to determine the site of the 2023 WCN. More on these important matters will be discussed in the next issue of World Neurology.

A final, and arguably the most important meeting, will also occur during the WCN. This will be the Global Neurology Alliance (GNA). The alliance represents most of the topic specialties of neurology, such as the World Stroke Organization, Alzheimers International, the International League Against Epilepsy, the International Parkinson’s Disease and Movement Disorders Society, the Multiple Sclerosis International Federation, the International Headache Society, the International Federation of Clinical Neurophysiology, and the major associated organizations, such as the World Federation of Neurosurgical Societies, the World Federation of Neurorehabilitation, the International Brain Research Organization, the World Psychiatry Association, and the International Child Neurology Association.

Also included are the major regional neurology organizations, such as the American Academy of Neurology, the European Academy of Neurology, the African Academy of Neurology, the Pan American Federation of Neurological Societies, the Pan Arab Union of Neurological Societies, and the Asian and Oceanian Association of Neurology.

WFN Specialty groups, such as Amyotrophic Lateral Sclerosis and Motor Neurone Disease, Huntington’s Disease, Tropical and Infectious Neurology, Environmental Neurology, Migrant Neurology, Epidemiology, Functional Neurological Disorders, and others, are also included.

At present, the GNA does not include solely neuroscience or patient advocacy groups. The GNA represents what is arguably the most comprehensive advocacy group for all aspects of neurology. Topics likely to be considered are increasing the importance of brain health, the inequities of access to neurological care, and the burden of non-communicable neurological disease.

All up, the 2019 World Congress of Neurology promises to be a most memorable event. It is, as the Global Neurology Alliance illustrates, a celebration of all things neurological. I look forward to seeing you all in October. •

WFN Neurological Community Update

WFN president reviews neurology development around the world, IGAP, World Brain Day, WCN, and other key topics.

Wolfgang Grisold

A 2023 WFN survey of WFN member societies assessing knowledge and content of the IGAP, revealed a disconcerting low level and awareness. Activities and publications of the WFN are aimed to increase the awareness and practical implementation of IGAP (Displayed Q 4-8) (London Office: C. Hunte)

Welcome to the first issue of World Neurology in 2024. We hope you had a relaxing, festive holiday season, and we look forward to the new year. 2024 will be another positive year for neurology, and we as the neurological community of the WFN will have many opportunities to foster and support neurology.

Globally, neurology is developing well. This statement can be supported by developments in neuroscience and global developments. General neurology as well as the subspecialties are thriving; examples are stroke and worldwide stroke services, epilepsy, and new drugs for epilepsy, movement disorders, and MS. The new possibilities not only to diagnose, but also to treat some of the genetic diseases is an incredible advance, and breaks previous dogmas on therapy limitations and prognosis of some neurological diseases.

Regarding global development, important are the activities of the WHO. Worldwide, the WHO has 194 member states. Several WHO departments take care of present and emerging health problems of the world. The classification of neurological disorders still needs separation from mental disorders and requires a universal and globally accepted classification, which can be the basis for universally applied stable and more devoted structures.

A positive example for the development of classification is stroke and ICD-11, where the WHO ICD-11 classification will allow further implementation of stroke services worldwide. Despite this amazing success story, we must continue to develop the prevention as well as chronic care, disability, and palliative care in stroke patients on the other side of the spectrum.

The WHO has implemented a “brain health unit” that fosters and supports the implementation and development of neurology. One key development is the IGAP, which is based on policy and advocacy, therapy, prevention, innovation, research, and public health. This concept was accepted by all member states at the World Health Assembly in 2022. Despite its strong support for neurology and ultimately persons with neurological diseases, the echo and acceptance at the regional and country level still needs more powerful inputs.

Presently, the WHO is developing a tool kit for the implementation of IGAP, addressing all stakeholders. The WFN uses its channels of distribution to member societies, uses information at talks and presentations, has information on IGAP on its website, and has emphasized the IGAP and cooperation with the WHO at the World Congress of Neurology (WCN) 2023 and will continue to do so.

We want to emphasize this important IGAP activity for several reasons:

  1. It promotes neurology at all levels and everywhere (“Semper et unique“).
  2. It provides a well-structured concept on the establishment and needs of neurology, which can be adapted and used according to the individual local needs. This may differ according to the income status of countries.

The call to all member societies is to familiarize members and health systems with the IGAP, put it on the agenda of your society meetings, and try to promote it within your networks, including health authorities and other stakeholders.

The mission of IGAP and the role for the development of neurology is enormous. We want to remind readers of the important role of the ILAE and the WFN in its development. We share this common effort, and as stakeholders, we have to avoid competitive altruism. The common goal is implementation of neurology and improvement of the large number of persons affected with acute and chronicneurologic disorders, disability, and be on the forefront to prevent disease.

From the other tasks and programs of the WHO, such as brain health, fight meningitis and tuberculosis, and implementation of rehabilitation, we would like to remind readers of the WHO essential medicine list (EML), which we covered in the last issue of World Neurology in 2023. Successfully, more medications, one for epilepsy and two for MS, were added to the EML list. The EML is a dedicated WHO effort to make drugs available in all countries of the world. In some countries, there is a lack of registered drugs, deficits in registration, procurement, distribution, and affordability.

World Brain Day (WBD)

The WBD has become an annual event for the WFN community. It celebrates the day of WFN’s founding in 1957, chooses a yearly topic, and collaborates with topic-related societies and regions.

This year, we will continue supporting the important topic of brain health, and focus on brain health and prevention. The activities will be chaired by D. Dodick and T. Wijeratne, the WFN regions, and will receive professional help from the marketing firm Yakkety Yak.

Prevention in neurology is a powerful and often underestimated tool to prevent neurological diseases and has a wide range of interventions, from vaccination, to pharmacology, nutrition, and lifestyle modifications. As with diagnosis and treatment, all types of prevention need to be added to neurological curricula.

Communication: Meetings/Congresses and Education

Communication with the WFN‘s member societies is important. Please follow our website and social media. We also have a new medium called the WFN Service Page, which will be published every three months in the Journal of the Neurological Sciences (JNS). This will increase the reach of the WFN. We also encourage you to publish material from your society and your regions in World Neurology. If you consider publishing in a journal, please consider the JNS and eNS as official journals of the WFN.

Congresses such as the WCN 2023 always leave impressions and produce new insights, either at the meeting or in discussions and informal gatherings. We are happy to report we had a large number of persons participating virtually at this congress. This served two main purposes: to reach countries worldwide, who are unable to travel for financial and other reasons, and to increase the worldwide spread of neurology. One hundred and thirty two countries participated.

There is material on the WFN website from the WCN 2023 in Montreal. Also, please note the summary of the plenary sessions, the coffee talks, and all abstracts are now published in the JNS.

Meeting with the Korean Committee in Seoul.

The next WCN will be in Seoul in 2025. The program committee has started its work. It is a generous venue and and a vibrant city. The Korean Neurological Society is putting much effort into this important congress, and it will provide strong input for neurology in the region.

For September 2024, we are planning a virtual educational update meeting: World Federation of Neurology Digital Update 2024 (WNU2024) Sept. 26-27. Eminent speakers will provide an update on the most frequent diseases, and the meeting will offer online teaching courses on these topics.

It will be a useful update instrument between the WCN congresses. Updates, education, and CME will be the strategy. The meeting will be virtual only.

WFN educational days will be continued, with the AFAN WFN educational day on neuropathies on Feb. 17, 2024, followed by a joint headache day with AFAN and GPAC/IHS. Another educational day with the AOAN is planned. This format has been successful, attracting  many attendees, not only from the regions, but worldwide. Recordings of the meeting can be seen in the WFN e-learning hub.

The WFN president high above Seoul.

We need to encourage and increase our efforts for CME and continuous professional development (CPD) worldwide. This is an essential part of professional practice in neurology, and needs constant update and development. Worldwide, many countries have established CME programs, belonging to the portfolio of practicing neurologists and are often linked with recertification. Usually the time of participation in a meeting or an activity is converted into a system of credits. This works well for individual countries but, for many reasons, in most circumstances cannot be exchanged or compared.

For large international congresses such as the WCN, the UEMS EACCME system is used, which has a detailed and strict separation of industry and other possible influences on the scientific program. This system is acknowledged by most European countries, and it also has an agreement with the American Medical Association and the Canadian Royal College of Physicians.

The WFN has a Standards and Evaluation Committee (chaired by Prof. Laszlo Vescey) in place that receives applications for meetings and events which fulfil the criteria of the WFN . This committee endorses international meetings according to the requirements of the WFN. The endorsed meeting is allowed to use the WFN logo for its event.

This was a short update on important WFN activities. Please follow us on our website and social media as well as the new WFN service page in JNS for more information. •

Raad Shakir Named a Commander of the British Empire in the U.K. New Year Honors List

Citation was for “services to global neurology”

Commentary on the CBE Award for Prof. Raad Shakir by WFN President William M. Carroll

Prof. Raad Shakir has been a prominent figure in neurology in the United Kingdom for more than 20 years and was one of the key persons in the organization of the successful London 2001 World Congress of Neurology. His contributions to both neurology in the U.K. and to the World Federation of Neurology (WFN) have been witnessed by many.

He has provided dedicated service over many years aided by his multicultural education and experience. Together with his detailed understanding of the varied cultural sensitivities in the global neurological community, he has been a successful leader. Before being elected to the position of Secretary-Treasurer General of the WFN in 2009, he had assumed this position in 2007 on the unexpected retirement of the incumbent. He immediately displayed these skills and commitment in this new role. With then-WFN President Johan Aarli, he was able to negotiate an understanding with the Peoples Republic of China, which enabled the Chinese Neurological Society to join the WFN without fracturing the memberships of the Hong Kong and Taiwanese neurological societies. This was no easy task as two previous WFN presidents had been less successful.

His WFN presidency commenced in 2014 and was marked by a commitment to empower the regional WFN organizations. This was crowned by the establishment of the African Academy of Neurology (AFAN) in 2015 and its first Congress in Tunis in early 2017. Although Dr. Shakir did not instigate the WFN African initiative in 2006, there is no doubt his enthusiasm at the time and his subsequent leadership enabled the initiative to be transformed into the AFAN and for AFAN to take its place as an active regional affiliated WFN organization.

As WFN President, Dr. Shakir also led WFN support for the African initiative to develop two neurological training centers each in both Anglophone and Francophone Africa. An early limitation was the funding of these centers. Through his energy, enduring funding was established to the benefit of neurology in Africa. Such an outcome both freed up valuable WFN funds for additional educational projects and elevated the visibility and support for the WFN. The benefit of WFN’s increased recognition as leader in neurological education in one of the most difficult yet needful areas of the world will pay dividends for many years through elevating the standard of neurological care in Africa.

The development and establishment of the Pan American Federation of Neurological Societies also occurred in Latin America during Dr. Shakir’s presidency. His influence and guidance were fundamental in driving this successful outcome.

Dr. Shakir displayed the same dedication and skill in WFN dealings with the World Health Organization (WHO). Intimate involvement with WHO-related activities such as the Neurology Atlas of 2017 and in heading the neurology Topic Advisory Group for the revision of the International Classification of Diseases (ICD-11) required enormous effort, patience, and skill over a considerable period of time.

The WFN and the global neurological and stroke communities are indebted to Dr. Shakir for his efforts. The interaction between the WFN and the WHO has led to a fundamental change in the way the WHO now views stroke (as a disease of the brain) and in the classification of neurological diseases in ICD-11. Both will be advantageous to the promotion of neurological care worldwide, and both are a direct result of his inspirational leadership and the respect in which he is held by all.

He is a worthy recipient of this prestigious award. •

XXIV World Congress of Neurology in Dubai

By William Carroll

The Dubai World Congress of Neurology (WCN) was held Oct. 27-31 and was an outstanding success. On behalf of the organizing committees, I congratulate all those who worked so hard to ensure it was a successful congress and all those who participated in it to share and contribute to the success. I will first list the statistics that provide the skeleton for this assessment of the congress and then deal with those “intangibles” that make this conclusion certain.

Emerati neurologists Dr. Reem Ahmed Al Suwaidi and Dr. Hamdan Al Zarouni, and WFN President William Carroll providing their opening comments at the Opening Ceremony to the XXIV WCN in Dubai.

The Opening Ceremony set the stage for the need for an increased effort to meet the burgeoning/looming crisis of non-communicable neurological disorders (NCNDs) confronting the world. In an aptly orchestrated commencement scene, two young Emirati neurologists (Dr. Reem Ahmed Al Suwaidi and Dr. Hamdan Al Zarouni) gave the bald facts of the estimated number of people facing neurological disability from dementia, stroke, migraine and headache, epilepsy, multiple sclerosis, and the other NCNDs, which make them the leading cause of disability and second leading cause of death globally.

Short addresses from the Director General of the Dubai Health Authority, His Excellency Humaid Alqatami, in the presence of His Highness Sheikh Ahmed bin Mohammed Al Maktoum, and from the presidents of the Emirates Neurology Society (Suhail Al Akrun) and the World Federation of Neurology (myself) echoed the need for action. The closing item was a short but powerful visual presentation highlighting the Emirates Neurology Society and the Pan Arab Union of Neurology, the WCN, and the current role of the World Federation of Neurology (WFN).

Dr Riadh Gouider read the citation for Dr. El Aloui Faris.

A total of 4,000 participants attended from a record number of 129 participating countries, 800 of whom were from the Middle East and North Africa. As expected, the majority of the 800, numbering some 580, were from the United Arab Emirates (UAE), Saudi Arabia, and Egypt. Despite the volatility in the region, countries such as Iran, Iraq, Lebanon, Syria, Kuwait, and Jordan had between 15 and 70 delegates each, a testament to their determination to attend and the generally helpful assistance in visa procurement from the Dubai Department of Tourism.

Overall, India had the largest number of attendees at about 400 followed by the UAE, Indonesia, the U.S., Saudi Arabia, the Philippines, China, South Korea, Egypt, and Japan with 100 making up the top 10 countries by numerical attendance.

Prof. Suhail Al Akrun, president of the XXIV WCN, handing over the XXV WCN in Rome to Prof. Antonio Federico of the Italian Society of Neurology.

Of the total attendees who specified their professional role, 80% were clinicians or clinician researchers. Ten percent were students or basic science researchers. Of the 64% who specified an age bracket, the age range was spread fairly evenly between those younger than 35 years old, the 35-44 year olds, the 45-54 year olds and the 55-64 year olds. Those aged younger than 45 years comprised 44% while those older than 45 years made up 56%. Altogether, these broad demographic details fit the WFN target population, although a higher percentage of younger attendees would have been more satisfying.

Nevertheless, a record number of bursaries and travel grants, 200 in all, were offered to and accepted by young neurologists from low and low-middle income countries.

Like meetings of any size, the program content and quality of the presenters is paramount to success. From the first plenary session, it was evident this was going to be the case with this World Congress. Prof. Patrik Brunden’s lecture on “The Battle to Beat Parkinson’s Disease” was outstanding for its clarity and message and will mark a new perspective on the future understanding and hope for disease course modification. Prof. Russell Foster’s lecture “Light, Circadian Rhythms, and Sleep: Mechanisms to New Therapeutics” was another masterful exposition of how a complex topic can be discussed with crystal-clear clarity. He described the identification of a third photoreceptor system based on photoreceptor retinal ganglion cells (pRGCs) using blue light sensitive melanopsin and how these pRGCs control the gene expression of the molecular pathway’s primary circadian pacemakers within the supraoptic nucleus and then the sleep wake cycle.

WFN medal awardee Dr Mark Hallett (contribution to neurological science), flanked by WFN President William Carroll and AAN President James Stevens.

WFN medal awardee Dr Mustapha El Aloui Faris (contribution to international neurology), flanked by WFN President William Carroll and AAN President James Stevens.

Together with the other plenary lectures delivered each morning of the congress, these provided a veritable banquet of highly informative and interesting topics characteristically beyond the usual fare clinicians are exposed to. (See Figure 1.) They will undoubtedly stimulate young and older attendees to explore neuroscience and “edge” neurology with increased or renewed zeal. It is this blend of cutting-edge material presented alongside new research and clinical practice experience from the regular main topics and the teaching course material that is at the heart of a successful World Congress.

Altogether 264 invited speakers presented eight main topics, each of three to four 1.5 hour sessions with three speakers, 25 other topics of one to two 1.5 hour sessions, six regional sessions, 25 teaching courses each of three hours, three early morning teaching courses of one hour each, 1,438 posters (370 each day) and the extraordinary Tournament of the Minds. This year, 15 teams entered with each team comprising four members and subjected to carefully prepared questions to remove any language advantage or disadvantage.

Dr Jun Kimura read the citation for Dr. Hallett on behalf of Dr Hiroshi Shibasaki.

The Tournament of the Minds proved a real competition and an immensely enjoyable educational event from its outset until the final as the last event on the Thursday. This too proved to be a hard-fought competition between the teams from Sri Lanka, Malaysia, India, and Hong Kong, all from the Asian and Oceanian Association of Neurology, until Hong Kong, coming from behind, emerged victorious. Congratulations to Drs. Wing Chi Fong, Ping Wing Ng, Annie Mew, and Andrew Chan and congratulations also to the Tournament of the Minds team of Richard Stark, Nick Davis, Faouzi Belhasen, and Serenella Servidei. (See photos on page 10.)

At the commencement of this column, I mentioned the “intangibles” which I believe are the hallmark of a truly successful congress. Together, these comprise a feeling that permeates all aspects of the congress for almost everyone through the 4.5 days. One sees people relaxed, enjoying the program, interacting with colleagues in an easy confident manner, seemingly relishing all aspects of the meeting. It stems from a good “connected” feeling that is no doubt the result of the quality of the scientific and teaching program, the lecturers and chairs, the congress app, the high quality of the AV and the AV service personnel, the ease of getting from one lecture room to the next, the exhibition, and the quality of the lunches and tea and coffee break refreshments.

Many other events occurred during the congress. The prestigious WFN medals were presented to Dr. Mustapha El Aloui Faris for service to international neurology and to Dr. Mark Hallett for contributions to neuroscience (see photos below), while the Ted Munsat prize for educational activities had a worthy recipient in Dr. Sarosh Katrak. There were numerous WFN committee meetings, including that of the Global Neurology Alliance, a relaxed meet and greet of young neurologists, and the selection of Montreal as the site for the 2023 WCN. The Montreal bid, led by Guy Rouleaux, defeated those of Mexico City (led by Miguel Osorna Guerra) and Rio de Janeiro (led by Fernando Cendes) for the right to host the XXVI WCN. The WFN is most grateful to all those who prepared their cases so well for this important decision.

For the first time, the WFN made a concerted effort to disseminate important messages emanating from the WCN through our inaugural Press Office, managed by Ashley Logan of Yakety Yak, and through the WFN social media outlets orchestrated by Kenes (Simona Milenkova and Milush Bahanov), the WFN e-communications committee (Walter Struhal and Tissa Wijeratne) and Yakety Yak (Ashley Logan). The WFN is most grateful to all those who contributed to this remarkable effort to showcase important elements of the WCN. (See Figure 2, which details this exceptional output, on page 2.)

At the closing ceremony, Prof. Suhail Al Akrun, president of the XXIV WCN, handed over the XXV WCN in Rome to Prof. Antonio Federico of the Italian Society of Neurology.

The XXIV World Congress of Neurology was an outstanding success, and the World Federation applauds all associated with the event for making it so. •

The plenaries at the World Congress of Neurology in Dubai.


The battle to beat Parkinson’s Disease

Patrik Brunden. See text of President’s report.


Precision Medicine in Neurology: Contributions by the Autozygome

Fowzan Al Kuraya described how populations enriched for autozygosity can contribute through unmasking the recessiveness of informative deleterious alleles.


Reading in the Brain: Mapping the Massive Impact of Literacy

Stanislas Dehaene elaborated on the investigation of several cognitive functional systems in the human brain but concentrated on the effect of the inferior right temporal lobe visual word form area and its relation to reading and to dyslexia.


Into the Grey Zone:  Detecting Covert Conscious Awareness in Behaviourally Non-Responsive Individuals

Adrian Owen described research using fMRI, EEG, and functional near infra-red spectroscopy to detect covert conscious awareness in patients in vegetative or “comatose” states and then communicate with some of these through visual imagery thoughts.


Light, Circadian Rhythms and Sleep: Mechanisms to New Therapeutics on the Underlying Mechanisms

Russell Foster. See text of President’s report.


Treating Huntington’s Disease

Sarah Tabrizi described promising disease modifying therapy approaches that target proximal pathogenetic mechanisms ranging from DNA-targeting Zn-finger proteins, transcription activator-like effector nucleases and CRISPR/Cas9, to post-transcriptional huntingtin lowering methods by RNA interference, antisense oligonucleotides and small molecule splicing modulators together with a range of developments in biomarkers and drug delivery techniques.


Imaging Pain

Irene Tracey explained the recent advances in the understanding of chronic pain in the individual by investigating the perceptual and non-perceptual changes in pain perceptual pathways induced by sensitization, amplification or attenuation through functional and structural plasticity. Importantly, chronic pain is now such a burden it is recognized as a disease in its own right in ICD-11.


What is Genomics Teaching Us About Neurodegeneration

John Hardy explained that the gene loci involved in late onset neurodegenerative disease are associated with damage response processes and the observed pathology marks the type of failed damage response.


Multiple Sclerosis

Mar Tintore outlined the advances in understanding MS, its earlier diagnosis, more effective treatments and the influence of lifestyle and co-morbidities all leading to reduced disablement.


Brain Machine Interfaces: From Basic Sciences to Neurorehabiltation

Miguel Nicolelis described groundbreaking research leading to primate brains directly interacting with mechanical, computational and virtual devices without interference of body musculature or sensory organs. Such observations are pointing to the concept that the properties of neurally-controlled robotic limbs or tools can be assimilated by brain representations as if they were extensions of the subject’s body.


The Promise of the Brain Initiative for Those With Neuro/Mental/Substance Abuse Disorders

Walter Koroshetz. The changing emphasis of informed interventions based on previously invisible dynamic features of brain circuitry as opposed to the older static disease and treatment paradigms based on anatomy and pathology was highlighted in this visionary account of  the impact of evolving technologies through the US Brain Research through Advancing Neurotechnologies and similarly aligned initiatives from around the world. •

Press releases during and following the XXIV World Congress of Neurology in Dubai


Oct. 28, 2019

Esteemed Panel of World’s Leading Stroke Experts from the World Stroke Organization Share Breakthrough Research on Relationship Between Stroke Risk and Vascular Dementia During Press Conference Broadcast via Facebook Live from XXIV World Congress of Neurology. Dubai, UAE
Potential audience 92.6 million


Oct 28, 2019

New Research on Migraine in the Workplace Unveiled During Press Conference to be Broadcast via Facebook Live from the World Congress Neurology, Dubai, Oct, 8 a.m. GST
Potential audience 80.58 million


Oct. 29, 2019

Effect of Climate Change on the Brain, Link to Alzheimer’s and Parkinson’s, to Be Key Focus of Discussion at XXIV World Congress of Neurology.
Potential audience 117.7 million


Oct. 24, 2019

World Federation of Neurology Reveals New Frontiers in Epilepsy Treatment for Children, Pregnant Women and New Links Between ADHD and Epilepsy at 24th Annual World Congress of Neurology, Dubai.
Potential audience 75.5 million


Oct. 23, 2019

World Federation of Neurology Joins Forces with the World Health Organization, Announcing “Groundbreaking” Reclassification of Stroke as a Disorder of the Brain; Launches Nine-Country Survey, Leading to Roadmap for Improved Neurological Care.
Potential audience 86.02 million


Post Congress releases during the week that commenced Nov. 11, 2019

The Prognosis for MS is Changing Due to Advancements in Treatment and Awareness, Yet Access to Care is Top of Mind for Global Neurologists


Pregnancy No Longer Believed to Modify Trajectory of MS, Experts Say


New Biomarkers Identified in Parkinson’s Disease Could Change Entire Trajectory of Parkinson’s Diagnosis and Treatment


Social media during the XXIV World Congress of Neurology in Dubai


Website: Over 311K page views from 75K people of whom 78% were new users. The top 5 countries were India, the USA, the UAE, Japan and Indonesia who went to pages on Registration Abstracts and Scientific program.


Targeted Google campaigns generated more than 17K clicks and almost 2.3M views, while social media campaigns generated over 10K clicks and 900K views. •

The Painful Truth of Migraine

A World Federation of Neurology and International Headache Society collaboration.

By Tissa Wijeratne, Wolfgang Grisold, David Dodick, Mohammad Wasay, and William Carroll

The Global Burden of Diseases Collaborators confirmed that neurological disorders are the leading cause of disability worldwide1. Globally in 2016, neurological disorders were the leading cause of disability-adjusted life years (276 million [uncertainty interval 247-308] and the second leading cause of deaths at 9.0 million [8.8-9.4]).

The world map printed on top of the hemispheres in the brain. The gold color denotes the World Federation of Neurology. The navy blue denotes the International Headache Society. The red denotes the pain.

Migraine is the most burdensome illness in people under the age of 50 (the group who contributes most to society through the workforce) and, in females2-4. Among people with migraine who experience more than 15 days per month with headache, 20 percent are occupationally disabled. Migraine with aura is associated with a 20 percent increased risk of mortality, and the suicide rate among people with cluster headache is 20 times the national average.

Lack of research support for and publications in the field of migraine from low-to-middle-income countries is disappointing and alarming5. The situation in high-income countries is still in tremendous need of progress. For example, in the United States, migraine and headache disorders are the least funded research area disproportionate to its disease burden compared to other diseases. Migraine is responsible for 46 percent of the U.S. disability burden due to neurological diseases and stroke, but migraine research comprises just 0.6 percent of federal funding.

In Australia (despite being a high income country) the estimated lost productivity in 2018 along with it was nearly 40 billion Australian dollars6,7. The national research funder of Australia—National Health and Medical Research Council (NHMRC)—allocated only less than 0.09 percent of total annual research budget during the 2007-2017 decade toward migraine, despite migraine being the highest cause of disability in Australia7,8.

It is indeed time for the World Federation of Neurology (WFN) to partner with International Headache Society (IHS) with a view to taking this important issue head-on with an energetic global campaign. We are determined to dedicate 2019 to raising awareness for the most common brain disorder in the world.

Key Messages

  • World Brain 2019 jointly with International Headache Society.
  • WFN will provide educational and promotional material.
  • Get on board now; let’s spread the news through mainstream media, social media platforms, and national and international meetings throughout the year.
  1. Migraine: The Painful Truth
  2. Prevalence: Migraine is the most common brain disease in the world, affecting one in seven people worldwide.
  3. Disability: Migraine is one of the leading causes of disability in the world and can severely impact every aspect of life.
  4. Education: Migraine is underrecognized, underdiagnosed, and undertreated.
  5. Research: Migraine receives less research funding than all of the world’s most burdensome diseases.
  6. Standard of Care: Migraine is a disease in which the majority of sufferers do not get the help they need.

In September 2017, the historic first Global Patient Advocacy Summit was convened, bringing together all stakeholders, including patients and patient advocates (IHS-GPAC). After a full day of presentations from all stakeholders and a robust discussion, a series of consensus statements that reflect the priorities and advocacy goals for the future were developed and presented as the Vancouver Declaration on Global Headache Patient Advocacy 20189.

The main outcomes of the summit included:

  1. It is important to understand and promote global, regional, and local interests of people with headache disorders as well as challenge their pervasive stigma.
  2. All patients affected by headache should have reliable access to competent medical care.
  3. All health care professionals should have adequate access to adequate training in headache medicine.
  4. A global benchmark should be established to ensure that all patients affected by headache disorders receive an accurate diagnosis and evidence-based treatment.
  5. Information is needed about consultation, diagnosis, treatment of headache disorders, and patient-reported outcomes (e.g. quality of life, satisfaction with treatment).

People who have a migraine or a headache disorder have a right to receive appropriate, evidence-based, and safe care.

  1. Correct diagnosis so that treatment is appropriate (as per IHCD classification)10,11.
  2. Access to the standard of care treatment regardless of financial situation, gender, culture, or place that your patient lives.
  3. Receive treatment by educated clinicians at all stages of your patient’s journey (acute treatment as well as preventive treatment).
  4. Receive treatment that is personalized and takes into consideration age, gender, culture, goals, and the patient’s changing needs over time (acute treatment and preventive treatment).

Behind these numbers are real lives

We will soon be able to share a series of educational and promotional materials that can be used in your country to advocate for better care for your patients.

The World Brain Day | Migraine: The Painful Truth is an important priority. The educational and promotional material from the WFN-IHS collaboration will help neurologists to be the best advocates for your patients with migraine and other headache disorders. •


  1. Collaborators , G.B.D.N.D.C., Global, regional, and national burden of neurological disorders during 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurol, 2017. 16(11): p. 877-897.
  2. Steiner, T.J., et al., Migraine is first cause of disability in under 50s: will health politicians now take notice? J Headache Pain, 2018. 19(1): p. 17.
  3. Collaborators, G.B.D.H., Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol, 2018. 17(11): p. 954-976.
  4. Reuter, U., GBD 2016: still no improvement in the burden of migraine. Lancet Neurol, 2018. 17(11): p. 929-930.
  5. Mateen, F.J., et al., Headache disorders in developing countries: research over the past decade. Cephalalgia, 2008. 28(11): p. 1107-14.
  6. Lynne, P., Migraine in Australia Whitepaper. 2018., accessed 20th March 2019
  7. Wijeratne T, Crewther .D., Crewther S. Migraine: The Greatest Disability of All in Australia. in Neuroepidemiology. 2018.
  8. Wijeratne , T., Out of sight, out of mind, Migraine the hidden cost of disability 2018., accessed 19th March 2019
  9. Dodick, D., et al., Vancouver Declaration on Global Headache Patient Advocacy 2018. Cephalalgia, 2018. 38(13): p. 1899-1909.
  10. Li, D., A.F. Christensen, and J. Olesen, Field-testing of the ICHD-3 beta/proposed ICD-11 diagnostic criteria for migraine with aura. Cephalalgia, 2015. 35(9): p. 748-56.
  11. Olesen, J., From ICHD-3 beta to ICHD-3. Cephalalgia, 2016. 36(5): p. 401-2.